The Clinic.

TROUBLE WITH GROIN PAIN

I'm 62 years old and a longtime runner. I run about 25 miles per week with one day off. I stretch for about ten minutes after running, but still seem to be chronically tight. After I run, I feel a mild strain in my inner thigh, up close to the pelvis. I always include a couple of stretches for this area, but even after several months it doesn't seem to help. Any suggestions?

Karl Bucholz

Shorewood, WI

The causes for unresolved groin pain, which increases with activity; are multiple, and most are difficult to treat. Once the more obvious causes are ruled out by exam and x-ray (including degenerative hip joint disease, fractures, obvious adductor muscle strain, genitourinary problems, and palpable hernias), there are a group of more subtle and insidious injuries. These can take many months to resolve, or may drag on chronically. They include a sports hernia, adductor tendonopathies, osteitis pubis, and stress fractures of the pubic ramus or hip.

The history of symptoms for all these injuries can be similar. The predominant complaint is groin pain, usually, but not always, on one side, and most noticeable during exercise. The onset of pain is usually insidious, but often there is a single event marked by a tearing sensation. Sit-up motions or coughing and sneezing may increase the pain.

Osteitis pubis is usually an overuse injury secondary to repetitive trauma to the pubic symphysis. This is the area at which the right and left sides of the pelvis meet together at the top of the groin. One explanation is due to the shear forces from contractions of the abdominal muscles and the hip adductor muscles (inner side of the thigh). These muscles may be very active in running, cutting, and kicking. The shear forces result in fatigue of the ligament between the two sides of the pelvis. X-rays can usually confirm the diagnosis showing a stress fracture initially and ultimately subtle degeneration of the bone at its margin, although a bone scan is sometimes needed. A bone scan involves the use of an intravenous radio-isotope and can also help rule out other possible causes of groin pain.

The "sports hernia" is really a description of a multitude of injuries or disruptions of the inguinal canal. This is generally the area under the skin, from the inside front of your hipbone to the groin area, where the thigh meets the body. It is at this region that the abdominal muscles meet the groin, and, in males, where the spermatic cord exits to enter the scrotum. An obvious defect in the muscle wall of the region is what is referred to as a hernia. Any less obvious defects such as strains of tendons or muscles that form the walls of the inguinal canal (that can't be felt on exam) may be grouped together as a sports hernia. These can often be difficult to treat.

Pulls and strains of the adductor muscles are the most common sources of the pain you've described. Strains are very small tears in the muscle, the tendons attaching the muscle to bone, or of the tissues surrounding and supporting these structures. The adductor muscles attach to the pubic bone at the groin level by the tendons. Micro tears at the level of the tendon or at the junction of the tendon and bone can cause groin pain. The tissue directly covering the bone is called the periosteum, and it may become mildly inflamed with repetitive stress from the attached tendon. The combination of tendinitis and perosteal reaction is sometimes called tenoperiostitis.

Since your pain has persisted over a period of months, you should see a sports medicine professional for an evaluation. Any time pain is ignored over a long period, you increase your chances of permanent or chronic impairment. Initial treatment for all of these injuries should include RICE (rest, ice, compression, and elevation). Gentle stretching and non-aggravating activity should follow until pain decreases to the point when walking is normal. Rehabilitation involves regaining full, pain free hip range of motion, and includes light resisted strengthening activities. Walking, light jogging and cross training are appropriate. Finally, sport specific training, which includes a gradual return to pain-free running, can take several months or longer.

Robert Scott, MD.

San Diego, CA

CALF MUSCLE INJURY

I am 52 years old. Three months ago I injured my lower right calf while running. At first I felt a sharp pain in the center of the back of my calf leaving me unable to run and barely able to walk without limping. Over the next few days, there as some swelling in the lower back side of my leg, about six to eight inches above my ankle--not exactly where I felt the initial pain, but it is where I've had problems since. I iced the area regularly and took some anti-inflammatory medication. After about ten days, the swelling subsided a bit; however, some swelling still persists. There is a lump at the base of my calf on the inside of my right leg. The front of the leg also became bruised, although nothing happened to cause a bruise--I'm assuming it was related to the injury.

Very carefully, I resumed walking and running after two to three weeks of rest and was able to do so without pain (despite the obvious lump). I gradually worked back to my original routine only to have the same injury return in the same area after about two months of running. I have now stopped running and am waiting for the lump to subside. Although I think I could probably resume running without pain, I do not want to make this a chronic problem.

I ran in a marathon six months ago (before these problems began) and returned to running about 30 miles per week until the first injury. Prior to the injury, my schedule generally included four five-mile runs a week and a 10 to 12 mile run on the weekend. I have prescription orthotics and was using them at the time of injury. Also, on both occasions I was doing a typical workout at a normal pace--no speed work, no extra distance--although I was going up hill when it happened the second time. Both times it happened toward the end of a run. I have been running for about 20 years and this is the first time I've had any problems. What should I do to rehabilitate and prevent this injury?

James Sheehan

Orange, CT

First, you should see a sports medicine professional to make sure that your injury is in fact in the calf muscle and not the Achilles tendon. If you have injured your muscle, a few visits to a physical therapist who is knowledgeable in running mechanics would be useful to review your orthotics and running form.

Your calf may simply be the victim of poor biomechanics. Your body is generally less forgiving of training flaws as you age. A physical therapist can also try aggressive soft tissue massage to break up some of the scar tissue in the calf. The lump you feel is very likely scar tissue from the injured muscle.

Once a good diagnosis is made, a gradual return to running should be all right. Be sure to avoid hill work and allow for recovery days for the first month, running no more than every other day. While you are slowly returning to running, the most important part of your rehabilitation should be stretching your calves and hamstrings. Your physical therapist will be able to give you exercises to make sure flexibility is maintained throughout the lower body. Any tightness in the muscles may contribute to a weak link at the site of the previous injury and cause a recurrence.

Craig J. Davidson, M.D.

Seattle, WA

This sounds like a rupture of the plantaris longus muscle--a small muscle at the back of the leg. It frequently ruptures in runners who may hear a popping sound when the rupture occurs. After a few hours or even after a few days, a collection of blood (hematoma) may be seen either at the site or more frequently at the front of the leg or even at the ankle. The lump will remain permanently but is not a cause for concern since the plantaris does not have a major function. You can resume running slowly and gradually after the acute injury has healed. Older runners are more susceptible to this injury.

It is very important to see a sports medicine physician for an acute injury. You deserve a professional diagnosis and professional treatment so that you can return to running safely and avoid chronic and recurring injury.

Ron Lawrence, MD., Ph.D.

Malibu, CA

ARE YOU BOTHERED BY AN INJURY? DO YOU HAVE A TRAINING OR DIET QUESTION?

Ask The Clinic, in care of The American Running Association. 4405 East West Highway. Suite 405. Bethesda, MD 20814, FAX [phone], or e-mail at [e-mail]. Write a letter Including as much relevant information as possible about you (age, weight. etc.) and your injury (type and location of pain), training schedule (typical weekly workouts, pace, surface), athletic and medical history, sole wear, recent changes in training, etc. Type or print your letters. Hand-written FAXed letters cannot be accepted. All letters, even e-mail, must include your name, address and phone number. Responses usually take three to four weeks, but can take as long as five.

RELATED ARTICLE: DID YA KNOW...

Baby Boomers suffered more than one million sports injuries in 1998, an increase of 33% over 1991. Check out Boomeritis, a new web site by the American Academy of Orthopedic Surgeons and the American Orthopedic Society for Sports. The joint effort is devoted to education regarding sports injury prevention, treatment, and rehabilitation.